Awake brain mapping makes for some potentially entertaining surgery

LIFESCIENCES11-19-2006
at left is Dr. Mitch Berger, UCSF Brain surgeon, who is doing an awake brain mapping of Bruce Hill at rt. Hill is a school principal from Bakersfield. Though the skull is opened up, exposing the brain, Hill is awake and responding to questions. Hill has a brain tumor that must be removed.
Penni Gladstone / The Chronicle Event on 9/19/06 in San Francisco.
Penni Gladstone / The Chronicle MANDATORY CREDIT FOR PHOTOG AND SF CHRONICLE/ -MAGS OUT less

LIFESCIENCES11-19-2006
at left is Dr. Mitch Berger, UCSF Brain surgeon, who is doing an awake brain mapping of Bruce Hill at rt. Hill is a school principal from Bakersfield. Though the skull is opened up, ... more

Photo: Penni Gladstone

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LIFESCIENCES11-19-2006
at left is Dr. Mitch Berger, UCSF Brain surgeon, who is doing an awake brain mapping of Bruce Hill at rt. Hill is a school principal from Bakersfield. Though the skull is opened up, exposing the brain, Hill is awake and responding to questions. Hill has a brain tumor that must be removed.
Penni Gladstone / The Chronicle Event on 9/19/06 in San Francisco.
Penni Gladstone / The Chronicle MANDATORY CREDIT FOR PHOTOG AND SF CHRONICLE/ -MAGS OUT less

LIFESCIENCES11-19-2006
at left is Dr. Mitch Berger, UCSF Brain surgeon, who is doing an awake brain mapping of Bruce Hill at rt. Hill is a school principal from Bakersfield. Though the skull is opened up, ... more

Photo: Penni Gladstone

Awake brain mapping makes for some potentially entertaining surgery

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Bruce Hill was doing some Monday morning proselytizing about his Mormon faith, which is not unusual except that his skull was spread open and Dr. Mitchel S. Berger was tinkering with the temporal lobe.

Hill was awake and talking during his brain surgery so that Berger could test his language skills. There was a tumor in there that had to come out. And the only way to know what brain matter could safely come out with it was to ask the patient.

The procedure is called awake brain mapping and it works as a process of elimination. The surgeon uses an electrical charge to inactivate an area of the brain. Then the patient is presented with a question, in the form of a word or object drawn on a computer screen. If he can answer correctly with that area inactivated, then that tissue can be removed without causing brain damage.

"We need to find out where his language pathways are and where they're not, because every person on the planet has different language wiring," says Berger, professor and chairman of Neurological Surgery at UCSF Medical Center.

What brought Hill to the table was the recurrence of a glioma, the common form of brain cancer, a tumor that had been removed seven years ago. Back then he'd suffered a grand mal seizure while asleep at his home in Bakersfield. Hill's wife Debbie asked their doctor "if this was your husband, where would you take him," and the answer, given without hesitation, was "Dr. Berger at UCSF." Berger earned that reputation by taking a mapping test for epilepsy, which affects the surface of the brain, and modifying it to find tumors, which run much deeper.

The first time around for Hill, Berger removed a tumor the size of a walnut. Hill then went back to his job as an assistant high school principal at Shafter High School, and hadn't missed a day of work in years. But recently Debbie started noticing him losing words, forgetting names and confusing his right with his left -- all signs of mini-seizures. An annual MRI, taken a few months ago, confirmed that the tumor was starting to grow back.

Four days before surgery Hill was in a different classroom setting as a student of Dr. David Perry, neuropsychologist at UCSF. As he did with the first surgery, Perry would be giving Hill his language task test and he wanted to make sure there were no surprise questions.

"The purpose is to test the brain," Perry, 49, said to Hill, also 49, "not to test you."

Two pages of ordinary images flashed on a computer screen -- a book, chair, hammer, gun, saw, donkey, window, horse, basket, pear, pineapple. It was the same test as for Hill's first surgery, in 1999, and hestill remembered an answer he got wrong. "There's the pig," he says. "I missed it last time."

This time, as he's on the operating table, Hill leads the medical team in an opening prayer. Then he is put under anesthesia while a question mark-shaped incision is cut around his left ear. The skin is brought over the forehead and pinned in place. The skull is drilled, and a 2-by-3-inch section of the temporal bone lifted off.

Next, Hill is awakened. While waiting for the language test to begin, he's glad to answer any questions about the Mormon church. It's like being in the dentist's chair -- patient and doctor chat back and forth. "You're doing good Bruce," says Berger, 53, while opening the thin, waxed paper-like cover of the brain. "I hope you're the one who is doing good," Hill answers back, risking a quip from the operating table. Berger sprays the exposed brain with a mister to keep it moist and says "this is irrigation fluid, not perfume," risking a quip of his own.

The brain is a dull white color with thin cross-hatches of red. The area hiding the tumor is divided into numbered sections with tiny pieces of paper. There are 25 numbers and Berger will check each one three times, to separate the active from inactive areas.

Hill lies on his right side and Perry wheels the computer screen in front of his face. A microphone is placed before him so Berger can hear the answers over the buzzing of the equipment. Because the tumor is on the left side, which is associated with language, there will be no math on the test.

Perry starts flashing the pictures on the computer screen, and Hill hits them as if he's been studying. "Window, owl, elephant, football, scissors, hammer."

Before Perry asks each question, Berger receives a cue to stimulate a tiny piece of brain with an electrical current, offering about the same juice as a transistor radio battery. "When the brain is sick with a lot of tumor in it, it can be very, very sensitive," says Berger, who uses an electrode to apply the charge. "You walk a fine line between stimulating the tissue and potentially causing a seizure."

Suddenly that line is crossed. Hill starts getting confused, his brain waves spiking on an EEG monitor. He calls a door a car. Then he starts calling every picture chicken. The brain is irritated and Hill suffers a mild seizure. You have to let it pass, so Berger cools the brain down with the mister then gives Hill a rest, leaving the room for 15 minutes.

When he comes back, he says "Bruce, you and I go back a long way now. We're going to beat this thing together."

Hills answers now come crisply and accurately -- "pineapple, lightbulb." Finally comes the picture he remembers from the last surgery and he atones for his previous mistake. "There's the pig, this time," he says, so triumphantly he has to be told not to elaborate on his answers.

By the end of the test, he has been awake for 80 minutes. "My head is sore," he says.

"All right, Bruce," Berger says before putting him back to sleep. "Now we got that tumor in our sights, but we've got to go get it."

That requires going 2 inches deep into the temporal lobe. Luckily for Hill, Berger is able to get all of the cancer, without taking away any function. The surgery takes 8 hours. The tumor, off-color and firmer than the normal tissue, is excised, minced and sent to the lab. Three days later, Debbie Hill was driving her husband home.

Reached by phone a week later, Hill was speaking well and "feeling really good." He remembers taking the test, and getting the pig right, but not the seizure. It will take a while to get names and numbers back. Asked for his address, he has to look it up in a church directory.